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    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <title></title>
    </head>
    <body>
    <form METHOD="POST" ACTION="/ONG/index.php?controller=voluntario&action=insert" class="contact-form" name="contactform" >
     All Fields Required | * Your answer is for planning purposes only and will not influence your selection into the program
    <br><br>
    <div class="clear"></div>
    <label>First Name *</label><input type="text" name="nombre" class="textfield" value="">
    <div class="clear"></div>
    <label>Last Name *</label><input type="text" name="apellidos" class="textfield" value="">
    <div class="clear"></div>
    <label>Gender</label>
        <input type="radio" name="sexo" checked="checked" value="1">Male &nbsp;&nbsp;&nbsp;
        <input type="radio" name="sexo" value="0">Female<br><br>
        
    <label>Email Address *</label><input type="text" name="email" class="textfield" value="">
    <div class="clear"></div>
    
    <label>Date of Birth *</label>
    
        <select size="1" name="mes">
        <option value="mm">MM</option>
        <option value="01">01</option>
        <option value="02">02</option>
        <option value="03">03</option>
        <option value="04">04</option>
        <option value="05">05</option>
        <option value="06">06</option>
        <option value="07">07</option>
        <option value="08">08</option>
        <option value="09">09</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
        </select> 
        
        <select size="1" name="dia">
        <option value="dd">DD</option>
        <option value="01">01</option>
        <option value="02">02</option>
        <option value="03">03</option>
        <option value="04">04</option>
        <option value="05">05</option>
        <option value="06">06</option>
        <option value="07">07</option>
        <option value="08">08</option>
        <option value="09">09</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
        <option value="13">13</option>
        <option value="14">14</option>
        <option value="15">15</option>
        <option value="16">16</option>
        <option value="17">17</option>
        <option value="18">18</option>
        <option value="19">19</option>
        <option value="20">20</option>
        <option value="21">21</option>
        <option value="22">22</option>
        <option value="23">23</option>
        <option value="24">24</option>
        <option value="25">25</option>
        <option value="26">26</option>
        <option value="27">27</option>
        <option value="28">28</option>
        <option value="29">29</option>
        <option value="30">30</option>
        <option value="31">31</option>
        </select> 
        
        <select size="1" name="anio">
        <option value="yyyy">YYYY</option>
        <option value="1943">1943</option>
        <option value="1944">1944</option>
        <option value="1945">1945</option>
        <option value="1946">1946</option>
        <option value="1947">1947</option>
        <option value="1948">1948</option>
        <option value="1949">1949</option>
        <option value="1950">1950</option>
        <option value="1951">1951</option>
        <option value="1952">1952</option>
        <option value="1953">1953</option>
        <option value="1954">1954</option>
        <option value="1955">1955</option>
        <option value="1956">1956</option>
        <option value="1957">1957</option>
        <option value="1958">1958</option>
        <option value="1959">1959</option>
        <option value="1960">1960</option>
        <option value="1961">1961</option>
        <option value="1962">1962</option>
        <option value="1963">1963</option>
        <option value="1964">1964</option>
        <option value="1965">1965</option>
        <option value="1966">1966</option>
        <option value="1967">1967</option>
        <option value="1968">1968</option>
        <option value="1969">1969</option>
        <option value="1970">1970</option>
        <option value="1971">1971</option>
        <option value="1972">1972</option>
        <option value="1973">1973</option>
        <option value="1974">1974</option>
        <option value="1975">1975</option>
        <option value="1976">1976</option>
        <option value="1977">1977</option>
        <option value="1978">1978</option>
        <option value="1979">1979</option>
        <option value="1980">1980</option>
        <option value="1981">1981</option>
        <option value="1982">1982</option>
        <option value="1983">1983</option>
        <option value="1984">1984</option>
        <option value="1985">1985</option>
        <option value="1986">1986</option>
        <option value="1987">1987</option>
        <option value="1988">1988</option>
        <option value="1989">1989</option>
        <option value="1990">1990</option>
        <option value="1991">1991</option>
        <option value="1992">1992</option>
        <option value="1993">1993</option>
        <option value="1994">1994</option>
        <option value="1995">1995</option>
        <option value="1996">1996</option>
        <option value="1997">1997</option>
        <option value="1998">1998</option>
        </select>
    <div class="clear"></div><br>
    <label>Current Address</label><input type="text" name="direccion" class="textfield" value="">
    <div class="clear"></div>          
    <label>City </label><input type="text" name="ciudad" class="textfield" value="">
    <div class="clear"></div> 
    <label>State </label><input type="text" name="estado" class="textfield" value="">
    <div class="clear"></div> 
    <label>Zip code </label><input type="text" name="zip" class="textfield" onkeypress="return justNumbers(event);">
    <div class="clear"></div> 
    <label>Country </label><input type="text" name="pais" class="textfield" value="">
    <div class="clear"></div> 
    <label>Cell Phone Number *</label><input type="text" name="telefono" class="textfield" onkeypress="return justNumbers(event);">
    <div class="clear"></div>
    <label>How can we contact you? </label>     
    <input type="radio" name="contactar" value="Phone">Phone &nbsp;&nbsp;&nbsp;<input type="radio" name="contactar" value="Email">E-mail
    <div class="clear"></div><br>
    
    <label>How did you hear about SientePeru? </label> 
    <div style="float:left;">    
    <input type="radio" name="escuchar" value="A Friend">A Friend<br>
    <input type="radio" name="escuchar" value="Facebook/Social Media">Facebook/Social Media<br>
    <input type="radio" name="escuchar" value="University ListServ">University ListServ<br>
    <input type="radio" name="escuchar" value="University Club">University Club<br>
    <input type="radio" name="escuchar" value="Other: ">Other:<input type="text" name="other" class="textfieldother" value=""><br><br>
    </div>
    <div class="clear"></div><br>
    
    
    <h5><cufon class="cufon cufon-canvas" alt="EMERGENCY " style="width: 80px; height: 14px; "><canvas width="92" height="14" style="width: 92px; height: 14px; top: 0px; left: -2px; "></canvas><cufontext>EMERGENCY </cufontext></cufon><cufon class="cufon cufon-canvas" alt="CONTACT " style="width: 63px; height: 14px; "><canvas width="75" height="14" style="width: 75px; height: 14px; top: 0px; left: -2px; "></canvas><cufontext>CONTACT </cufontext></cufon><cufon class="cufon cufon-canvas" alt="INFORMATION:" style="width: 91px; height: 14px; "><canvas width="103" height="14" style="width: 103px; height: 14px; top: 0px; left: -2px; "></canvas><cufontext>INFORMATION:</cufontext></cufon></h5>
    <div class="clear"></div> <br>
    <label>Full Name </label><input type="text" name="emernombre" class="textfield" value="">
    <div class="clear"></div>
    <label>Address </label><input type="text" name="emerdireccion" class="textfield" value="">
    <div class="clear"></div>
    <label>Phone </label><input type="text" name="emerTelefono" class="textfield" value="" onkeypress="return justNumbers(event);">
    <div class="clear"></div>          
    <label>E-mail </label><input type="text" name="emerEmail" class="textfield" value="">
    <div class="clear"></div>
    <label>Do you have any<br> allergies or food restraints? Please list them here. </label><textarea name="alergias" id="message" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div> 
    <label>Please fill out the following information about your current/completed college education. </label><textarea name="educacion" id="message" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div> 
    <label>College</label><input type="text" name="colegio" class="textfield" id="college" value="">
    <div class="clear"></div> 
    <label>College City</label><input type="text" name="colegioCiudad" class="textfield" id="city" value="">
    <div class="clear"></div> 
    <label>College State</label><input type="text" name="colegioEstado" class="textfield" id="state" value="">
    <div class="clear"></div> 
    <label>Graduation Year (or projected)</label><input type="text" name="graduacion" class="textfield" id="state" value="" onkeypress="return justNumbers(event);">
    <div class="clear"></div> 
    <label>Major(s)</label><input type="text" name="mayor" class="textfield" id="state" value="">
    <div class="clear"></div> 
    <label>GPA </label><input type="text" name="gpa" class="textfield" id="cel" value="">
    <div class="clear"></div>
    <label>Which program location are you most interested in?
    (Please note: Volunteer preference is considered in placement but not guaranteed.  We ask our volunteers to be open to working where their help is most needed.)
    </label>     
    <input type="radio" name="localizacion" value="Trujillo">Trujillo 
    <br><input type="radio" name="localizacion" value="Otuzco">Otuzco
    <br><input type="radio" name="localizacion" value="Pacasmayo">Pacasmayo
    <br><input type="radio" name="localizacion" value="No preference: Place me where I am most needed">No preference: Place me where I am most needed
    <div class="clear"></div><br>
    
    <label>When are you available to volunteer? </label> 
    <div style="float:left;">    
    <select name="primercombo" size="1" onchange="replace(this.options.selectedIndex)"> 
         <option>Winter 2013</option>
         <option>Fall 2013</option>
         <option>Spring 2014</option>
         <option>Summer 2014</option>
     </select>
    
     <select name="segundocombo" size="1"> 
         <option value="Winter: December 18 - January 12">December 18 - January 12</option>
         <option value="1 month: May 19 - June 20">May 19 - June 20</option>
         <option value="1 month: June 23 - July 25">June 23 - July 25</option>
         <option value="1 month: July 30 - August 30">July 30 - August 30</option>
         <option value="2 months: May 19 - July 25">May 19 - July 25</option>
         <option value="2 months: June 23 - August 30">June 23 - August 30</option>
         <option value="3 months: May 19 - August 30">May 19 - August 30</option>
         <option value="1 month: September 16 - October 14">September 16 - October 14</option>
         <option value="1 month: October 14 - November 11">October 14 - November 11</option>
         <option value="1 month: November 11 - December 9">May 19 - August 30</option>
         <option value="2 months: September 16 - November 11">September 16 - November 11</option>
         <option value="2 months: October 14 - December 9">October 14 - December 9</option>
         <option value="3 months: September 16 - December 9">September 16 - December 9</option>
     </select>     
    </div>
    <div class="clear"></div><br>
    <label>Which program(s) are you interested in?  (List up to two choices in order of preference.) </label>
    <div style="float:left;"> 
    1. <select name="programa1" size="1"> 
         <option value="Clinical Medicine">Clinical Medicine</option>
         <option value="Social Work">Social Work</option>
         <option value="Teach English">Teach English</option>
         <option value="Teach Music">Teach Music</option>
         <option value="Engineering">Engineering</option>
     </select>
     <br>
     2. <select name="programa2" size="1"> 
         <option value="none">none</option>
         <option value="Clinical Medicine">Clinical Medicine</option>
         <option value="Social Work">Social Work</option>
         <option value="Teach English">Teach English</option>
         <option value="Teach Music">Teach Music</option>
         <option value="Engineering">Engineering</option>
     </select> 
    <br>
    </div>
    <div class="clear"></div><br>
    <label>Please describe your educational background and any relevant work experience. (Clinical/teaching experience, relevant courses, etc.) </label><textarea name="experiencia" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div>
    <label>Please describe your background in Spanish including courses taken, level of fluency and experience in a Spanish-speaking environment. 
    </label><textarea name="español" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div>
    <label>Please describe any volunteer or intercultural experiences you have had. </label><textarea name="intercultural" id="message" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div>
    <label>Is there anything else we should know about you? (Interests, hobbies, etc.) </label><textarea name="hobbies" id="message" class="textarea" cols="2" rows="2"></textarea>
    <div class="clear"></div><br>
    
    <h5><cufon class="cufon cufon-canvas" alt="PERSONAL " style="width: 69px; height: 14px; "><canvas width="81" height="14" style="width: 81px; height: 14px; top: 0px; left: -2px; "></canvas><cufontext>PERSONAL </cufontext></cufon><cufon class="cufon cufon-canvas" alt="STATEMENT:" style="width: 74px; height: 14px; "><canvas width="87" height="14" style="width: 87px; height: 14px; top: 0px; left: -2px; "></canvas><cufontext>STATEMENT:</cufontext></cufon></h5>
    <div class="clear"></div> <br>
    <label style="font-weight:normal"><b>Please prepare a brief personal &nbsp;statement addressing the following questions (500-1000 words): </b><br><br>
    •	How does participation in the Vive Peru program fit into your long-term plans? <br>
    •	What sets you apart from other program applicants?  What can you offer to the communities we serve? <br>
    •	Vive Peru volunteers come into very close contact with the Peruvian culture and &nbsp;&nbsp;way of life both at their homestays and at their &nbsp;work sites that may make them uncomfortable at first.<br>  Describe how you would react to an uncomfortable situation to make the experience positive for yourself and fellow volunteers?
    </label>
    <textarea name="declaracion" id="message" class="textarealot" cols="2" rows="2" onkeypress="return palabra(this,event)"></textarea>

    <div style="float:right; margin-right:50px;"><input type="submit" name="Send" value="Send"></div>
    </form>
    </body>
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